Early History of Rickets
Conditions with bony deformities have been described in ancient medical writings from the 1st and 2nd centuries.6 Soranus, a Roman physician in the 1st and 2nd century AD, had noted bony deformities more frequently among infants residing
in Rome than Greece, and attributed such a variation to lack of nurture and hygiene by Roman mothers.7 Galen, also of the same era, had described the classic bony deformities noted in rickets.6 Although such descriptions can be interpreted as evidence for existence of rickets, it was not until mid-17th century that
clear description of rickets emerged.6–8 In the mid-17th century England, rickets was endemic in the Southwest counties of Dorset and Somerset.6–8
Daniel Whistler, an English physician, is credited with the earliest description of rickets.6,8 In 1645, while a medical student at Leyden, Whistler published a monograph titled “Inaugural medical disputation on the disease
of English children which is popularly termed the rickets.”6 Whistler provided a succinct description of the signs and symptoms of rickets in his thesis and used an alternate term called
“Paedosteocaces” to describe the clinical symptoms of rickets.8 Medical historians have questioned the originality of Whistler’s report.8 It’s probable that Whistler’s report is based on hearsay rather than personal experience, as he was a medical student and
only 26 years of age at the time of its publication.
In 1650, Francis Glisson, a Cambridge physician published in Latin a treatise on rickets titled “De Rachitide.”7,8
Glisson’s work remains a classic among medical texts. Unlike Whistler,
Glisson’s sound and elegant observation of rickets
is based on clinical and postmortem experience.
Glisson’s writing reflects the transitional phase in medical thinking.6
Glisson’s treatise addresses the clinical features of rickets in a
scientific tone, but lapses into medieval mysticism while
discussing the etiology of rickets. Glisson
ascribed the etiology of rickets to “cold distemper, that is moist and
consisting
of penury or paucity of and stupefaction of
sprits.”6 Despite his affirmation of mysticism in the cause of rickets, Glisson was convinced that rickets was neither contagious nor
heritable.9
His conclusions regarding the relationship of age to onset of rickets
has stood the test of times: “We affirm therefore,
that this disease doth rarely invade children
presently at birth, or before they are six months old; (yea, perhaps
before
the ninth moneth) but after that time it beginneth
by little and little daily to rage more and more to the period of
eighteen
moneths, then it attaineth its pitch and
exaltation, and as it were resteth in it, till the child be two years
and six month
old: so that the time of the thickest invasion is
that whole year, which bears date from the eighteenth month, two years
and
half being expired, the disease falleth into its
declination, and seldom invadeth the child, for the reasons already
alledged.”7,9
Glisson’s suggested treatments for rickets included: cautery, incisions to draw out bad humors, blistering, and ligature of
soft wool around the limb to retard the return of blood.7
For correction of bony deformities, Glisson proposed splinting and
artificial suspension of the affected infant: “The artificial
suspension of the body is performed by the help of
an instrument cunningly made with swathing bands, first crossing the
brest
and coming under the armpits, then about the head
and under the chin, then receiving the hands by two handles, so that it
is a pleasure to see the child hanging pendulous in
the air, and moved to and fro by the spectators. This kind of exercise
is thought to be many waies conducible in this
affect, for it helpeth to restore the crooked bones, to erect the bended
joynts,
and to lengthen the short stature of the body.”7
There were no new advances in the study of
rickets for nearly 2 centuries after the Glissonian era. At the turn of
the 20th
century, rickets was rampant among the
underprivileged infants residing in industrialized cities of North in
the United States
and several polluted cities in Europe. In 1909,
among infants 18 months or less who had died, Schmorl found
histopathological
evidence of rickets in 96% (214 of 221) at autopsy,
highlighting the pervasive nature of rickets during that era.10
Despite its common occurrence, the exact etiology of rickets remained
elusive. Deficient diet, faulty environment (poor hygiene,
lack of fresh air and sunshine), and lack of
exercise were all implicated in its etiology. Dietary animal
experiments, appreciation
of folklore advocating the anti-rachitic properties
of cod-liver oil, and epidemiologic understanding of the geographical
association of rickets to lack of sunshine were all
relevant in resolving the “rickets” puzzle. The late 19th century and
early 20th century witnessed a phenomenal expansion
in the knowledge of rickets. Understanding the histopathology of
rickets,
advances in biochemical and radiologic testing,
clarification of the anti-rachitic features of cod-liver oil and
ultraviolet
light were all responsible for the conquest of
rickets as a malady.6 Alfred Hess referred to this era as “the second great chapter” and the “renaissance” in the history of rickets.3
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